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Dawn Gandy, RN, BSNClinical Informatics Coordinator
Rosemary Kennedy, PhD, RN, MBA, FAANPresident & CEO, eCare Informatics
Cape Regional Health System
Meaningful Use Stage 2 eCQMs: The Survival Kit
Session Objectives
Share our approach for achieving MU Stage 2 requirements for Clinical Quality Measures
– Opportunities– Challenges– Lessons Learned
Cape Regional Health System
242 Licensed Beds Average Daily Census ~ 85 45, 000 Annual ED Visits $110,000,000 Annual Revenue Clinical affiliation with University of Pennsylvania
Health System Sole acute care provider in Cape May County, NJ Seasonal volume fluctuations Highly competitive environment
Cape Regional Health System
Cape Regional Medical Center
Cape Regional Physician Associates – Inpatient Hospitalist Program– 34 Outpatient Providers– 10 Locations
Cape Regional Urgent Care Cape VNA partnership with Central Jersey VNA Health Information Exchange
– New Jersey Southern Health Information Network Exchange (NJSHINE)
– Partnered with Inspira Health Network and Shore Medical Center
Cape Regional Health System
Cape Regional Health System
• Multi-vendor environment– Patient Registration: Meditech v5.66– EDIS: Allscripts ED– EHR: Soarian Clinicals 3.4– Laboratory: Meditech v5.66– Radiology: Meditech ITS v5.66– OB: GE Centricity– HIM/Patient Billing: Meditech v5.66
Cape Regional Health System
Systems Environment
• Stage 1 – Achieved September, 2012– 14 Core Measures– 5 of 10 Menu items
• Stage 2 – Achieved September, 2014– 16 Core Measures– 3 of 6 Menu Items– 16 of 29 Clinical Quality Measures
Meaningful Use
Cape Regional Health System
Clinical Quality MeasuresKey Players
Deborah Baehser, RN MSHAVice President, Patient Care Services
Noreen DiPadova, BS RRTDirector of Performance Improvement
Claire Paugh, BS MBAManager, Clinical Applications
Dawn Gandy, RN BSNClinical Informatics Coordinator
• Rosemary Kennedy, PhD, RN, MBA, FAANPresident & CEO, eCare Informatics
Cape Regional Health System
The Beginning
With Siemens assistance, conducted gap analysis Reviewed 29 available CQMs Reviewed current Soarian system design and operational practice and
workflow Compared NQF (National Quality Forum) and CQM reporting criteria
against current state Documented measures as achieved, achievable, and not applicable
(from an operational standpoint) Identified possible pool of measures to be used for meaningful use
attestation
Cape Regional Health System
The Good, Bad, andTHE UGLY
Challenges with Siemens gap analysis Information was overwhelming Difficult to understand the intent of each measure Difficult to determine source(s) of data and data location(s) needed for
reporting purposes (In our systems and the “Alphabet Soup”) Struggled to identify appropriate patient populations for each measure Deliverable was unwieldy spreadsheet How to translate operational opportunities for CQM compliance into
functional, useable data collection for attestation?
Cape Regional Health System
Preliminary CQM List (19)
Cape Regional Health System
Measure Description Measure Description
CMS 32 Median Time from ED Arrival to ED Departure for Discharged ED Patients
CMS 185 Healthy Term Newborn
CMS 111 Admit Decision Time to ED Departure Time for Admitted Patients
CMS 110 Venous Thromboembolism Warfarin Therapy Discharge Instructions
CMS 105 STK-06: Discharged on Statin Medication CMS 104 STK- 02 Discharged on Antithrombotic Therapy
CMS 107 STK-08: Stroke Education CMS 113 Elective Delivery
CMS 26 CAC-3: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
CMS 30 Statin Prescribed at Discharge
CMS 9 PC-05 Exclusive Breast Milk Feeding and the subset measure PC-05a Exclusive Breast Milk Feeding Considering Mother´s Choice
CMS100 ASA at Discharge for AMI
CMS 102 STK-10: Assessed for Rehabilitation CMS 55 Median Time from ED Arrival to ED Departure for Admitted ED Patients
CMS 72 STK 05: Antithrombotic Therapy By End of Hospital Day Two
CMS 31 Hearing screening prior to hospital discharge
CMS 108 Venous Thromboembolism Prophylaxis CMS 60 Fibrinolytic Therapy received within 30 minutes of hospital arrival
CMS 188 Initial antibiotic selection for community acquired pneumonia
CRMC Review
Weekend #1 (Dawn/Claire) Detailed reviewed of 29 available CQMs Worked with gap analysis documentation Identified measures that were impossible to achieve Identified pool of possible measures for inclusion
Reviewed with Core Team Attempted to finalize measure selection Feeling unsure and uncertain about understanding of measure
definitions and selected CQMs Frustrated, and concerned about ability to meet requirements
Cape Regional Health System
HELP!!!
Help is on the way … At this point, we engaged Rosemary and her team to assist
with our understanding of measures and our opportunities to comply
Brings valuable understanding of the measures and the intent of the legislation to the process
Third review of available CQMs begins – focused on 19 preliminarily selected
Cape Regional Health System
Weekend #2
Weekend retreat to review CQM requirements, Gap Analysis, and current system state Create order out of chaos Validate measure selection Start to truly understand what needs to be accomplished to
reach and report the measure Final decisions on measure selection
Cape Regional Health System
The Final 16
Cape Regional Health System
Measure Description Measure Description
CMS 32 Median Time from ED Arrival to ED Departure for Discharged ED Patients
CMS 185 Healthy Term Newborn
CMS 111 Admit Decision Time to ED Departure Time for Admitted Patients
CMS 110 Venous Thromboembolism Warfarin Therapy Discharge Instructions
CMS 105 STK-06: Discharged on Statin Medication CMS 104 STK- 02 Discharged on Antithrombotic The
CMS 107 STK-08: Stroke Education CMS 113 Elective Delivery
CMS 26 CAC-3: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
CMS 30 Statin Prescribed at Discharge
CMS 9 PC-05 Exclusive Breast Milk Feeding and the subset measure PC-05a Exclusive Breast Milk Feeding Considering Mother´s Choice
CMS100 ASA at Discharge for AMI
CMS 102 STK-10: Assessed for Rehabilitation CMS 55 Median Time from ED Arrival to ED Departure for Admitted ED Patients
CMS 72 STK 05: Antithrombotic Therapy By End of Hospital Day Two
CMS 31 Hearing screening prior to hospital discharge
Let the Fun Begin
Cape Regional Health System
Dive into each individual CQM to evaluate what we are currently capturing and what will need to either be added or changed
Created individual spreadsheets for each measure, comparing NQF with current practice and data available in Meditech, Allscripts, and Soarian
Identified operational workflows and system data that required updating
Changed practice, update systems, and educate physicians and nurses about changes
Quality Measure
Numerator/Denominator
Data and Codes
Parallel Work
1. Professional Practice
2. Data Representation
3. Workflow
4. EHR Application
5. Mapping and Interfacing
6. QRDASkill and Expertise1. Quality Measure Domain
Knowledge2. Project Management3. Technical Hands On4. Application Design5. Rollout, Education, and
Documentation
Cape Regional Health System
Measure 26:Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
Measure 26:Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
Measure 26:Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
20
Data Element Catalog (DEC)
Value Set Authority Center (VSAC)
PIVOT_ TablesQuick Search by Measure, Code, etc.
New Documentation
Cape Regional Health System
Expansion of Existing Documentation
Cape Regional Health System
Challenges …
Cape Regional Health System
Siemens Clinical Quality Measure Reporting Robust reporting mechanism available Allowed drill-down for analysis Struggled with identifying reasons why results did
not appear as expected ICD9 / SNOMED coding
Problem List
Cape Regional Health System
Problems were a problem!
Cape Regional Health System
Provider problems proved to be more difficult to implement than expected Drive much of CQM inclusion/exclusion criteria Difficult to differentiate between provider and nursing
problem list in Soarian Physician engagement is a must, and was difficult to obtain Physicians and nurses not playing well together in the Problem
List sandbox
Lessons Learned …
Cape Regional Health System
What would we do differently the next time? Engage Rosemary sooner! Don’t assume that the “easy ones” are really easy Promote/publicize the Meaningful Use initiative more
widely Allow more time for implementation of changes and the
associated learning curve Beware of unshared data
Next Steps …
Cape Regional Health System
Meaningful Use Stage 2 Attestation Validation & Refinement of current CQM
measures Looking forward to impacts of expected
program changes Meaningful Use Stage 3
Questions?
Contact Us
Cape Regional Health System
Dawn GandyClinical InformaticsCape Regional Medical [email protected](609) 463-2518
Rosemary KennedyPresident & CEOeCare [email protected](610) 715-2786
